Multidisciplinary rehabilitation after primary total knee arthroplasty: a randomized controlled study of its effects on functional capacity and quality of life.

OBJECTIVE: To examine whether a multidisciplinary rehabilitation programme can improve functional recovery and quality of life and reduce the use of rehabilitation services compared with conventional care one year after total knee arthroplasty. DESIGN: Prospective, randomized, non-blinded, controlled trial. SETTING: An outpatient centre-based setting. SUBJECTS: Eighty-six patients who were scheduled for primary total knee arthroplasty due to osteoarthritis of the knee. INTERVENTIONS: A ten-day multidisciplinary rehabilitation programme, which was focused on enhancing functional capacity, was organized 2-4 months after surgery. In both groups, a standard amount of physiotherapy was included in conventional care. MAIN MEASURES: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the 15D, 15-m walk test, stair test, isometric strength measurement of the knee. Use of rehabilitation services was asked about with a questionnaire. Outcomes were assessed preoperatively and at 2-, 6- and 12-month follow-ups. RESULTS: In both groups, functional capacity and quality of life improved significantly. The mean absolute change in the WOMAC function score was -32.4 mm (SD 26.4) in the rehabilitation group and -32.8 mm (SD 20.1) in the control group (P-time*group = 0.40). No difference was found between groups in any outcome measure or in the use of rehabilitation services during the study period. CONCLUSIONS: This study indicates that for knee osteoarthritis patients treated with primary total knee arthroplasty, a 10-day multidisciplinary outpatient rehabilitation programme 2-4 months after surgery does not yield faster attainment of functional recovery or improvement in quality of life than can be achieved with conventional care.

In vitro comparison of clodronate, pamidronate and zoledronic acid effects on rat osteoclasts and human stem cell-derived osteoblasts.

In the present study we compared the first generation non-nitrogen-containing bisphosphonate, clodronate with second and third generation nitrogen-containing bisphosphonates, pamidronate and zoledronic acid in dynamic rat osteoclast resorption and apoptosis assays and in human mesenchymal stem cell-derived osteoblast assay. We found that due to high bisphosphonate-bone binding affinity, bone surface exposure to clodronate for 3 min. had maximal resorption inhibition. The mechanism of action of both clodronate and zoledronic acid involved osteoclast apoptosis, whereas pamidronate had only minor apoptotic effect at dosages, which readily inhibited resorption. Zoledronic acid was not metabolised into an intracellular ATP-analogue in vitro in contrast to clodronate. All bisphosphonates had a dose-dependent inhibitory effect on the human bone marrow mesenchymal stem cell (hMSC)-derived osteoblast calcium deposition. None of the compounds had inhibitory effect on hMSC differentiation. Zoledronic acid was the most potent of all three bisphosphonates in terms of both apoptosis induction and resorption inhibition. Zoledronic acid efficacy might thus use its capacity to trigger osteoclast apoptosis in an unknown, but similar manner to that of the non-nitrogen-containing bisphosphonates. It appears that zoledronic acid has properties of both bisphosphonate classes and could well be the first member of a new class of bisphosphonates, by definition.

Survival of the AGC total knee arthroplasty is similar for arthrosis and rheumatoid arthritis. Finnish Arthroplasty Register report on 8,467 operations carried out between 1985 and 1999.

We report the survival of AGC knee endoprosthesis from the Finnish Arthroplasty Register for 2 indications, osteoarthrosis (OA, 6,306 knees) and rheumatoid arthritis (RA, 2,161 knees) during 1985-1999. Survivorship analysis was performed with revision as an endpoint. We found similar survival rates. In the OA group, survival after 5 years was 97% and it was 94% after 10 years. In the RA group the corresponding figures were 97% and 96%, respectively. There was no significant difference in survival whether or not cement was used for fixation. The revision rates were higher in men and in younger patients.

Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation.

INTRODUCTION: Antegrade intramedullary (IM) nailing of humeral shaft fractures is reported to cause shoulder joint impairment. This retrospective study compared shoulder joint symptoms, range of motion (ROM), and isometric strength after antegrade IM nailing and dynamic compression (DC) plating of humeral shaft fractures. MATERIALS AND METHODS: We compared 29 patients with DC plating and 44 with antegrade IM nailing of their humeral shaft fractures. Shoulder pain, L'Insalata and Constant scores, shoulder joint ROM and isometric shoulder strengths were measured after mean follow-up of 6.2 (1-15) years (DC plating) and 5.5 (2-10) years (IM nailing). RESULTS: Patients had nonsignificantly more shoulder pain after IM nailing than after DC plating. Shoulder scores and isometric strength measurements showed no difference between the groups. Flexion was significantly better after DC plating, but none of the other ROM parameters differed between the groups. The shoulder scores and all ROM and strength parameters of the injured side were significantly lower than on the uninjured side in both groups. CONCLUSIONS: Shoulder joint ROM and strength does not recover to normal after humeral shaft fracture. Antegrade IM nailing if performed properly is not responsible for shoulder joint impairment.

Nonbridging external fixation in the treatment of unstable fractures of the distal forearm.

INTRODUCTION: Unstable fractures of the distal forearm often require surgical treatment to restore the normal anatomy and function. We have used a relatively new technique, nonbridging external fixation, in the treatment of these fractures in our hospital during the past few years. Our results are presented here. MATERIALS AND METHODS: Fifty-two patients (41 female, 11 male) with an unstable fracture of the distal forearm were treated using nonbridging external fixation at Oulu University Hospital during 1996-1999. The patients' mean age was 57 years. There were 45 Colles-type fractures, and 7 distal radius fractures had a concomitant distal ulna fracture. Forty-three patients were reviewed after a mean of 16 months of follow-up to assess radiological, functional, and subjective results. RESULTS: The fixation device maintained reduction well during healing, and the final radiological result was good. Range-of-motion and grip strength were restored to levels of 87-98% compared with the uninjured forearm. The subjective result was rated as 8 (mean) on a scale of 0-10. Pin-tract infection was a common complication (19%), but such cases were easily treated with antibiotics. CONCLUSION: Nonbridging external fixation offers an easy, minimally invasive, and reliable technique in the treatment of unstable fractures of the distal forearm.

Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study.

BACKGROUND: The aim of our prospective, randomized, clinical study was to compare two postoperative regimens after Achilles rupture repair and determine whether early functional treatment will give a better result than early immobilization in tension of the musculotendinous unit. METHODS: Fifty patients with acute Achilles tendon rupture were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks. Full weight bearing was allowed after 3 weeks in both groups. The patients were assessed clinically at 1, 3, 6, 12, and 24 weeks, and the last control visit took place at a mean of 60 (SD 6.4) weeks postoperatively. RESULTS: The isokinetic calf muscle strength scores were excellent in 56%, good in 32%, fair in 8%, and poor in 4% of the patients in the early motion group at the last control checkup; whereas the scores in the cast group were excellent in 29%, good in 50%, and fair in 21% of the patients. The ankle performance scores were excellent or good in 88%, fair in 4%, and poor in 8% of the patients in the early motion group, whereas the scores in the cast group were excellent or good in 92% and fair in 8% of the patients. At 3 months and at the last control checkup, no significant differences were seen between the two groups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, isokinetic calf muscle strength, or overall outcome. The complications included one rerupture in the early motion group and one deep infection and two reruptures in the cast group. Deep infection and the rerupture in the cast group occurred in the same patient. The outcome of the complications was good in two cases and poor in one. CONCLUSION: The isokinetic calf muscle strength results were somewhat better in the early motion group, whereas the other outcome results obtained in the two groups of patients were very similar. We recommend early functional postoperative treatment after Achilles rupture repair for athletes and well-motivated patients and for less-motivated patients and nonathletes.

Surgical treatment of unstable fractures of the distal clavicle: a comparative study of Kirschner wire and clavicular hook plate fixation.

During 1988-1999 39 unstable fractures of the distal clavicle (Neer 2) were operated on in Oulu University Hospital. Kirschner wire (K-wire) fixation was used in 22 cases and a clavicular hook plate in 17. Shoulder symptoms and function were assessed using self-administered questionnaires devised by L'Insalata et al. (1997), and Constant scoring. Mean follow-up was 6.2 years in the K-wire fixation group and 2.0 years in the clavicular hook plate one. The mean L'Insalata scores were 91 in both groups (92% and 93% of the contralateral side) and the mean Constant scores 84 (95% and 90 (96%) for K-wire fixation and the clavicular hook plate, respectively. Complications commonly occurred with K-wires, which migrated in 12 cases, resulting in loss of reduction in 7 and infection in 3, and 2 cases of non-union. In the clavicular hook plate group, there was 1 complication, a fracture of the clavicle, and 2 cases of non-union. We conclude that shoulder symptoms were reduced and function restored to an adequate level by both methods, but complications were unacceptably frequent when K-wires were used. The clavicular hook plate was better in this respect and it is therefore recommended.